Cranial Arteritis: Delay in Diagnosis Can Cause Blindness

Friday

Jul 11, 2014 at 6:35 PM

Mary B. is a 62-year-old teacher who presents to her primary care physician (PCP) with a 10-day history of pain in the right jaw area and right forehead, which is aggravated by chewing. She has not experienced headaches previously and recalls no recent teeth clenching or trauma. Her PCP finds tenderness in the area of her right TMJ (where the jawbone connects to the skull just in front of the ear) and offers the diagnosis of TMJ Syndrome with a recommendation for Ibuprofen tablets and a heating pad.

Unfortunately, Mary experiences total loss of vision in her right eye four days later, prompting an urgent visit to her eye doctor, who makes the diagnosis of cranial arteritis with optic nerve damage due to loss of blood flow. In retrospect, Mary recalls brief clouding of vision in that eye 10 days prior, but she had not shared that information with her PCP since it seemed unrelated. The eye doctor begins treatment with Prednisone tablets after obtaining blood tests, preserving vision in the left eye, but the right eye remains permanently blind.

Take Home Points:

Cranial Arteritis (also known as “temporal arteritis” or “giant cell arteritis”) is an inflammatory disorder of blood vessels of unknown cause, which is seen primarily in patients over 50, and which can cause blindness as well as strokes. Involvement of the jaw muscles can also cause pain with chewing, as was seen in this case, which can be confused with TMJ syndrome. Patients in this age group should take care to report any visual symptoms in association with headache, but for some Cranial Arteritis patients, the first sign of visual involvement is blindness, so it is essential that screening blood test be performed promptly for all older patients who present with new, unexplained headaches.

The blood tests of interest are the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). If either of these tests is abnormal, the diagnosis can be confirmed with biopsy of the temporal artery. Prednisone therapy controls symptoms rapidly and can prevent blindness if treatment is begun promptly. This therapy should begin as soon as the diagnosis is suspected, before biopsy results are available. Given the critical importance of rapid treatment, it is essential for older patients to report new headache or visual symptoms promptly to their PCP. In severe cases, there may also be fever, weight loss, and scalp tenderness – all potential clues to this serious disease.

Mary B. is a 62-year-old teacher who presents to her primary care physician (PCP) with a 10-day history of pain in the right jaw area and right forehead, which is aggravated by chewing. She has not experienced headaches previously and recalls no recent teeth clenching or trauma. Her PCP finds tenderness in the area of her right TMJ (where the jawbone connects to the skull just in front of the ear) and offers the diagnosis of TMJ Syndrome with a recommendation for Ibuprofen tablets and a heating pad.
Unfortunately, Mary experiences total loss of vision in her right eye four days later, prompting an urgent visit to her eye doctor, who makes the diagnosis of cranial arteritis with optic nerve damage due to loss of blood flow. In retrospect, Mary recalls brief clouding of vision in that eye 10 days prior, but she had not shared that information with her PCP since it seemed unrelated. The eye doctor begins treatment with Prednisone tablets after obtaining blood tests, preserving vision in the left eye, but the right eye remains permanently blind.
Take Home Points:
Cranial Arteritis (also known as “temporal arteritis” or “giant cell arteritis”) is an inflammatory disorder of blood vessels of unknown cause, which is seen primarily in patients over 50, and which can cause blindness as well as strokes. Involvement of the jaw muscles can also cause pain with chewing, as was seen in this case, which can be confused with TMJ syndrome. Patients in this age group should take care to report any visual symptoms in association with headache, but for some Cranial Arteritis patients, the first sign of visual involvement is blindness, so it is essential that screening blood test be performed promptly for all older patients who present with new, unexplained headaches.
The blood tests of interest are the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). If either of these tests is abnormal, the diagnosis can be confirmed with biopsy of the temporal artery. Prednisone therapy controls symptoms rapidly and can prevent blindness if treatment is begun promptly. This therapy should begin as soon as the diagnosis is suspected, before biopsy results are available. Given the critical importance of rapid treatment, it is essential for older patients to report new headache or visual symptoms promptly to their PCP. In severe cases, there may also be fever, weight loss, and scalp tenderness – all potential clues to this serious disease.

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